Understanding Barriers, Facilitators Could Boost PrEP Adherence

Adherence to HIV pre-exposure prophylaxis (PrEP) remains suboptimal for many young men and transgender women of color who have sex with men, according to a recent study that examined the barriers and facilitators of the treatment.

The study, published in the journal AIDS and Behavior, included 31 participants, aged 15 to 24 years and found that 48% of participants had optimal adherence, defined as having “both urine tenofovir concentration consistent with dose ingestion within 48 hours and pharmacy refills consistent with >4 doses per week use.”

“We know that there are substantial barriers to adherence in this population, and it’s important that we understand what those barriers are so that we can develop programs that really address the specific needs of these populations,” Sarah Wood, MD, MSHP, assistant professor at the University of Pennsylvania Perelman School of Medicine, told Contagion^®.

Barriers include stigma, health system inaccessibility, side effects, competing stressors and low risk perception. At least 1 barrier was reported by 81% of participants. Facilitators included social support, health systems accessibility, reminders/routines, high risk perceptions, and personal agency. All participants with optimal adherence and 69% of those with suboptimal adherence reported at least 1 facilitator.

“The group that was adherent, so had that optimal adherence measure, were more likely to talk about a sense of empowerment, or we called it personal agency, in relationship to taking PrEP,” Wood said. “So, these were the people who talked about PrEP as part of their general wellbeing, PrEP as part of their future orientation to stay healthy, or PrEP as part of a motivation for them to meet the other goals that they had in the future.

Understanding what motivates patients to maintain adherence to PrEP will make practitioners better equipped to harness those motivations to improve treatment.

“So, if someone is really motivated to stay HIV negative because their goal is to go to college, how do we really frame our messaging for that individual about PrEP as a way to get to goal attainment?” Wood said. “If it’s to increase their intimacy with their partner, and that’s their motivation, how do we better tailor our messaging in that way. We don’t have a 1-size-fits-all package for PrEP. We really need to hear more about where individual patients are coming from and work with them to realize those goals.”

Health systems appeared in the study as both a barrier and facilitator to PrEP. Among the beneficial aspects of health systems were those that were perceived as nonjudgmental with respect to the patient’s identity, youth friendly, and included structural supports such as a PrEP navigator.

“We often take for granted that young people, especially when we think of emerging adults and that 18 to 24 age group, we often treat them as if they’re going to be savvy and navigate the health system on their own,” Wood told Contagion^®. “But the reality is our participants told us they’d never filled a prescription before. They didn’t know how to use their insurance. They had no idea how to tell the difference between what their pharmacy card was or their insurance card or how to get their PrEP without paying a substantial copay.”

Health system accessibility was the focus of a recent study in Ontario, Canada, that explored allowing nurses to dispense PrEP. Other studies also have examined health system barriers to PrEP adherence.

Wood said she was surprised at the level of social support from family members, as well as HIV-positive friends and partners, and targeting interventions that focus on social support networks is 1 possible area for improving adherence.

“A bunch of people talked about taking medications with their older relative, like taking their PrEP while their grandma took their Alzheimer’s medications, or taking PrEP with an uncle who had multiple medical conditions,” Wood said. “But the other population that really came through as being supporters was their HIV-positive friends and partners as well.”

Future research and implementation efforts should explore fostering personal agency and enhancing positive social interaction around medication taking, the study noted.